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Please print or type. <br />UNIFORM HAZARDOUS <br />1. GenCALrrO <br />"u mmT <br />be99830 <br />WASTE MANIFEST <br />5. Generators Name and Mailing Addre!T PROPELLER <br />2478 N WILCOX RD <br />STOCKTON, CA 95215 <br />209-982.400()-105 <br />Generator's Phone: <br />6. Transporter 1 Company NameAMERICAN VALLEY WASTE OIL, INC. <br />W <br />0 <br />w <br />Z <br />w <br />0 <br />Page 1 of 3. Emergent Response Phone <br />2OV98�2��0(]U <br />Generator's Site Address (if ci ferent than <br />2 Company Name <br />ST.ERICYCLE SPECIALTY WASTE SOLUTIONS, INC <br />GEM -RANCHO CORDOVA, LLC. <br />11855 WHITE ROCK RD. <br />RANCHO CORDOVA, CA 95742 <br />916-351-0980 <br />:acilitys Phone: <br />9a 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />HM and Packing Group (if any)) <br />1 RO, UN1263, WASTE PAINT RELATED MATERIAL, 3, PGII <br />Special Hanonng mstrucuona a -u ��u,,,�, �• ••• -••• ___ <br />PROFILE# 695534-02 PAINT WASTE ERG# 128 <br />EMERGENCY CONTACT: MIKE <br />Form <br />ed. OMB No. 2050-0039 <br />9 9 GBF <br />EPA ID NumberCAR000272302 <br />NNVS000110924 <br />U.S. EPA ID Number CAD980884183 <br />10. Containers 11. Total12. Unit <br />No. Type <br />Quantity Wt.Nol. <br />1 DM 55 G <br />13. Waste Codes <br />above by the proper <br />ping name, and are classified, <br />15. GENERATOR'SIOFFER0 t S and a el m allOres. 1 he n proper co d on for transport accordingat the te, its of this gto applicable nment are uilnte ationa and nationaly :: ii, accurately overnmental regulations.' If export shipment and I am the Phmary packaged, <br />marked and labeled/placarded, p proper <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment (b Consent. mall uanti generator) is true. <br />gen M th Day. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity, Signature or (b) q g ) U <br />GeneratoeslOiferoes Printed(fyped Name \ <br />livy ❑ Export from U.S. P o entrylexit: <br />_j 16. International Shipments Import to U.S. Date leaving U.S.: <br />i— <br />Z Transporter <br />w 17. TransW <br />nature (for exports omy): <br />Acknowledgment of Receipt of Materials <br />18. Discrepancy <br />El Type Residue <br />18a. Discrepancy Indication Space E]Quantity <br />Manifest Reference Numb <br />18b. Alternate Facility (or Generator) <br />J <br />U <br />LL- Facility's Phone: <br />W 18c. Signature of Alternate Facility (or Generator) <br />Q <br />Z <br />NMethod Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems <br />19. Hazardous Waste Report Management 3. <br />w 1 <br />2. <br />materials covered by <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous the m3igexcept <br />as noted in Item 18a <br />nature <br />--- <br />Print /Typed Ine <br />DESIGN <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. <br />donth Day ear <br />G <br />Month Day Year <br />�y104 <br />❑ Partial Rejection 11 Full Rejection <br />U.S. EPA ID Number <br />4. <br />IFEST SYSTEM <br />FACTO EPA's eMAN <br />